Implementation of the Good Life with osteoArthritis in Denmark (GLA:D ® ) program via telehealth in Australia: A mixed-methods program evaluation

Abstract

Introduction

We aimed to evaluate the implementation of the Good Life with osteoArthritis in Denmark (GLA:D^®) program via telehealth in Australia using Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation framework.

Methods

Using a convergent mixed-methods design, semi-structured one-on-one interviews with physiotherapist adopters and nonadopters of GLA:D^® via telehealth were analyzed thematically alongside the examination of registry data (1 March 2020–10 February 2022) from patients with hip or knee osteoarthritis completing GLA:D^® via telehealth (telehealth-only) or combined with in-person care (hybrid). Effectiveness was determined as changes from baseline to 3-month follow-up (mean differences, 95% confidence intervals, effect size) for Knee injury and Osteoarthritis Outcome Score (KOOS-12)/Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12), and chair stand test. Group- and individual-level changes were compared to published minimally clinically important change scores.

Results

Twenty-three interviews (12 adopters, 11 nonadopters) found key barriers/facilitators to reach and adoption, high perceived effectiveness, and strategies to support sustainability. Of 2612 registered patients, 85 (3%) and 115 (4%) completed GLA:D^® via telehealth-only or hybrid model, respectively. Most effectiveness outcomes were associated with moderate-large improvements. Group-level changes exceeded minimally clinically important change values for KOOS/HOOS-quality of life and chair stand test. Nearly two out of three patients reached a minimally clinically important change for KOOS/HOOS-quality of life. With telehealth-only and hybrid delivery, 99% (n = 82) and 85% (n = 97) were satisfied/very satisfied. Physiotherapist adoption was limited (n = 128, 6%).

Discussion

GLA:D^® delivered via telehealth is effective, had high patient satisfaction, and was perceived positively by physiotherapist adopters. Addressing low reach and adoption requires further implementation strategies to facilitate greater telehealth opportunities for patients and physiotherapists.

Keywords

Osteoarthritis implementation physiotherapy telehealth exercise program evaluation

Introduction

Osteoarthritis (OA) is a rapidly increasing global health concern, affecting over 500 million people worldwide.¹ The knee and hip account for 66% of OA cases, with prevalence increasing by 122% and 127%, respectively, over the last three decades.¹ Symptoms create a lifelong personal burden in adults, including poor health-related quality of life (QoL),² reduced physical activity,³ and greater likelihood of multimorbidity (e.g. heart diseases, diabetes).⁴ Exercise therapy,⁵ patient education,⁶ and weight loss⁷ (if indicated) are recommended first-line care in all contemporary guidelines.⁸ Exercise-therapy, supported by more than 50 randomized trials,⁵ is cost-effective⁹ and reduces knee replacement surgery rates in people with moderate-severe disease.^10,11

Good Life with osteoArthritis in Denmark (GLA:D^®) is an evidence-based, individualized, supervised, group education, and exercise-therapy program for people with knee and hip OA, now offered in eight countries.¹² Evaluation of GLA:D^® in Denmark, Canada, and Australia indicates clinically important improvements in patient outcomes, including reduced pain and improved joint- and health-related QoL at 3 and 12 months.^11–14 The reach of OA management programs like GLA:D^® to all people with OA is limited by barriers including patient beliefs and understanding of OA management, patient's personal costs, and the inability to access or commit to the program, particularly for individuals living in rural areas or with high occupational or family caring responsibilities.^11,15 Additionally, the need to attend 14 in-person group-based sessions (two education, 12 exercise therapy) over 8 weeks may represent a participation barrier for GLA:D^®. Telehealth, remotely delivered phone or video-based patient–clinician interaction¹⁶ could improve access to OA management programs like GLA:D^® for people with knee and hip OA. While recent meta-analyses suggest telehealth-delivered one-to-one physiotherapy is effective in reducing pain and improving function for knee OA in clinical trials,¹⁷ evidence for group-based care and real-world implementation is limited.

The COVID-19 pandemic provided an impetus to deliver GLA:D^® via videoconference-based telehealth. Supporting physiotherapists to rapidly adopt telehealth to deliver GLA:D^® was possible in Australia due to prepandemic work establishing its feasibility and acceptability,¹⁸ and processes and resources were developed as a part of a clinical trial which commenced in 2019.¹⁹ This work identified that GLA:D^® via telehealth was perceived as highly acceptable by patients, emphasized the benefits of reduced fear of exercise, improved function, and reduced pain.¹⁸

This mixed-methods project aimed to comprehensively evaluate the implementation of GLA:D^® via telehealth in Australia using physiotherapist and patient data and applying the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework.²⁰ Findings will inform future strategies to support GLA:D^® via telehealth in Australia and internationally, as well as the development, implementation, and scale-up of other education and exercise-therapy telehealth initiatives to support chronic disease management.

Methods

This study was guided by the RE-AIM QuEST framework to generate a deeper understanding of the implementation outcomes of GLA:D^® via telehealth in Australia. RE-AIM QuEST is a comprehensive framework that integrates qualitative and quantitative methods to evaluate the implementation of interventions (e.g., GLA:D^® via telehealth) beyond effectiveness alone for a more robust evaluation across five key dimensions: reach, effectiveness, adoption, implementation, and maintenance.²¹ It facilitates an understanding of implementation barriers and facilitators, examines the influence of multilevel contextual factors (e.g., patient, clinician, systems levels) on implementation and increases the likelihood of successful implementation or scale-up of the intervention in other “real-world” settings.²⁰

This study used data from two sources: (a) semistructured interviews with Australian GLA:D^® trained physiotherapists and (b) GLA:D^® Australia patient data registry. Merging these two sources would allow the generation of in-depth knowledge to identify targetable barriers to implementation, facilitate program improvements and adaptions, and assist with better implementation of GLA:D via telehealth. Reporting of this study was guided by the COnsolidated criteria for REporting Qualitative research (COREQ) checklist²² and Good reporting of a mixed methods (GRAMM) study checklist.²³ Ethical approval was obtained from La Trobe University's Human Ethics Research Committee (HEC21303) and (HEC21130).

The GLA:D program

In 2016, GLA:D^® was implemented in Australia to facilitate access to guideline-based patient education and exercise therapy for people with knee and hip OA. Trained physiotherapists deliver group-based education (2–3 sessions, 60 min) and exercise therapy (12 sessions, 60 min) over a 6- to 8-week period.

The exercise-therapy sessions focus on neuromuscular control and encompass core stability, joint alignment, leg strength, and functional exercises.^24,25 Exercises are individually tailored and progressed based on the physiotherapists clinical judgement and patients’ exercise capacity and pain acceptability over the duration of the program.

Intervention implementation process and support

At the onset of the COVID-19 pandemic in Australia (March 2020), the GLA:D^® Australia leadership team began supporting GLA:D^® trained physiotherapists to provide the program via telehealth for patients with hip and knee OA. On 23 March 2020, an email with guidance and instructions for how to offer GLA:D^® via telehealth was sent to all trained physiotherapists, and online resources to assist physiotherapists were posted on the GLA:D^® Australia website. This included suggestions on how to adapt education and exercise-therapy components for telehealth, safety considerations, and information on various online video conference platforms. A series of interactive webinars discussing how to manage potential telehealth challenges and live question and answer were held on 27 March, 1 May, and 14 August 2020. In April 2020, a list of sites (clinics and hospitals) across Australia where GLA:D^® was being provided by telehealth was added to the patient-facing section of the GLA:D^® Australia website. In May 2020, the GLA:D^® physiotherapist training course transitioned to fully online delivery and integrated content on delivering GLA:D^® via telehealth. Additionally, the GLA:D^® leadership team began hosting online participant education sessions in May 2020 to alleviate pressure on clinicians. Throughout the pandemic, each Australian state has had variable and changing levels of restrictions on providing in-person physiotherapy. GLA:D^® physiotherapists were never limited to solely provide GLA:D^® via telehealth, yet they were encouraged to follow local public health recommendations and consider implementing GLA:D^® via telehealth when appropriate.

Data sources and collection

Part 1: Qualitative data

Underpinned by an interpretive description paradigm,²⁶ in-depth one-on-one semistructured interviews were conducted via videoconference between 28 June 2021 and 14 October 2021 with a purposive sample of GLA:D^® Australia trained physiotherapists. All GLA:D^® Australia-trained physiotherapists (n = 2141) were eligible to participate. To obtain diverse perspectives on the decision to implement GLA:D^® via telehealth along with positive and negative perceptions or experiences with telehealth, recruited participants included both adopters and nonadopters. Adopters were physiotherapists who implemented GLA:D^® via telehealth (minimum of five patients with hip or knee OA registered in the data registry who attended GLA:D^® via telehealth-only or hybrid delivery model). Nonadopters included physiotherapists who did not implement GLA:D^® via telehealth.

An invitation to participate and study information were included in routine monthly GLA:D^® Australia email newsletters, as well as posted in the GLA:D^® Australia Facebook group. Additional snowball sampling and word of mouth were used during recruitment while seeking variability in physiotherapists’ location (urban or rural) and setting (public or private).

All interviews were conducted at a mutually convenient time for the participant and the interviewer (AE) using open-ended questions from topic guides that were reviewed by all authors (Supplemental Appendix A). The topic guides were informed by the normalization process theory²⁵ and structured to address each aspect of the RE-AIM QuEST framework.²⁰ The interviewer was a physiotherapist with 16 years’ clinical experience and a PhD in knee injury rehabilitation, who had extensive qualitative research experience. The interviewer had not been involved with GLA:D^® training in Australia, but was highly familiar with the program due to experience in Canada. The interviewer did not have preestablished relationships with any of the participants. Interviews were recorded, deidentified, and transcribed verbatim. Field notes were used to document initial impressions after each interview and later guide reflection and analysis. Analysis began concurrently during interviews and guided ongoing participant recruitment. Interviews ceased when the research team believed that the newly generated data was repeating what was expressed in previous data, and there was no further development of thematic categories, indicating saturation.²⁸

Part 2: Quantitative data

Patient-level data—GLA:D^® Australia Registry

Patients with pain and symptoms of hip and/or knee joint problems who present to trained physiotherapists are offered the three core program elements: patient education, neuromuscular exercise therapy, and registration in the online data registry, with an “opt-out” consent process approved by La Trobe University Human Ethics Research Committee (S17-193, HEC21303). Patients with joint pain resulting from something other than OA, including recent trauma, tumor, or inflammatory joint disease, or if they could not communicate in English, are excluded.¹¹ Patients who complete the baseline intake questionnaire are automatically emailed the 3- and 12-month follow-up questionnaires facilitated by Research Electronic Data Capture system. Patient-level data collection for the current project included all participants who registered in the data registry between 1 March 2020 and 10 February 2022. At the 3-month follow-up, eligible participants answered that they completed GLA:D^® entirely via telehealth (telehealth-only) or with a combination of telehealth and in-person including at least three telehealth sessions (hybrid).

Participant baseline demographics extracted from the registry included age (years), sex (male, female, intersex, prefer not to say), education (completed primary school; completed high school; completed apprenticeship, certificate, or diploma; university degree), employment (unemployed, home duties, studying, employed full or part time, retired), location (urban, rural, mixed),²⁹ and body mass index (BMI), calculated based on self-reported height and weight. In addition, data on the presence of comorbidities, most affected joint (hip or knee), and details on previous surgery to affected joint were obtained. Participant data on their treating physiotherapists, intended delivery method, and actual program delivery method, along with the number of GLA:D^® sessions they attended (education session: out of possible two; exercise therapy: out of possible 12), was also extracted. For those who attended via hybrid delivery model, number and proportion of telehealth sessions were summarized.

Patient-reported outcome measures examined at 3-month follow-up included: pain intensity (100 mm visual analogue scale [VAS]³⁰); Knee injury and Osteoarthritis Outcome Score (KOOS-12), or Hip disabillity and Osteoarthritis Outcome Score-12 (HOOS-12) summary measure and subscales of pain, function, and knee-related QoL³¹; surgery desire (“do you have so much pain and trouble from your knee/hip that you want to have surgery?” yes or no); perceived recovery on a global rating of change (scale −3 to 3; −3 = worse than ever; −2 = strongly worse; −1 = slightly worse; 0 = unchanged; 1 = slightly recovered; 2 = strongly recovered; 3 = completely recovered); and satisfaction with the GLA:D^® program (scale 1–5; 1 = not at all satisfied; 2 = not satisfied; 3 = neutral; 4 = satisfied; 5 = satisfied). Functional performance was evaluated using the 30-s chair stand test.³²

Health services-level data

Data pertaining to number, health service type (public, private), and location (state and urban, regional, rural) of sites, and number of physiotherapists providing GLA:D^® via telehealth were also extracted from the GLA:D^® Australia data registry.

Data analysis

Part 1: Qualitative

Qualitative interview data were first analyzed inductively using reflexive thematic analysis.²⁸ Concurrent data collection and analysis allowed topic guide questions to be revised, prompting further exploration of initial themes identified. The interviewer (AE, 17 years clinical experience, 7 years qualitative research experience) read and reread each transcript to gain familiarity and developed initial units of meaning and a coding structure, incorporating insight from field notes. A second researcher, new to qualitative research (JH, 14 years clinical experience), read and independently coded 50% of the transcripts. The researchers met numerous times for reflective discussion, along with a third experienced qualitative researcher (CB, 16 years clinical experience, 10 years qualitative research experience), to discuss and refine the data coding process, themes, and to ultimately agree on a thematic framework that aligned with the RE-AIM QuEST dimensions (Table 1). Further triangulation occurred with participant validation, performed by sharing the final themes with each interviewee for free comment. NVivo software (QSR International Pty Ltd, Melbourne) was used to organize data and support analysis.

Table 1.

Operationalized RE-AIM dimensions with qualitative and quantitative data framework.

RE-AIM Dimensions	Qualitative outcomes	Quantitative outcomes
Reach: Understanding patients who participated in GLA:D® via telehealth	Perceived barriers and enablers to patients accessing GLA:D® via telehealth	# of patients Sex, age, education, employment BMI, comorbidities Patient location (urban, regional, rural) Most affected joint (hip, knee)
Effectiveness: Impact of GLA:D® via telehealth on patient health outcomes	Perceived effectiveness of GLA:D® via telehealth	Average pain (VAS 100 mm) Symptoms, ADL, QoL: KOOS-12, HOOS-12 GROC, patient satisfaction Surgery desire Chair stand test
Adoption: Uptake of the GLA:D® via telehealth by physiotherapists and clinics	Perceived barriers and enablers to adoption of GLA:D® via telehealth	# Physiotherapists and # clinics providing GLA:D® via telehealth Type of health service (public, private) Clinic location (urban, regional, rural)
Implementation: The fidelity of GLA:D® via telehealth	Program modifications required to deliver via telehealth Implementation support or resources used or sought by physiotherapists	#/proportion of education sessions attended by patients #/proportion of exercise-therapy sessions attended by patients Number of telehealth sessions attended (hybrid group)
Maintenance: Ongoing and future implementation of GLA:D® via telehealth.	Role of GLA:D® telehealth in future Perceived barriers and enablers to GLA:D® telehealth sustainability	Observational trend in # new patients each month of evaluation period

#: number; ADL: activities of daily living; BMI body mass index; GROC: global rating of change; HOOS-12: Hip Disability and Osteoarthritis Outcome Score-Short Form; KOOS-12: Knee Injury and Osteoarthritis Outcomes Score; QoL: quality of life; VAS: visual analogue scale.

Part 2: Quantitative

Table 1 outlines the quantitative operationalization of the RE-AIM QuEST dimensions. Each element of the framework was examined and summarized descriptively using frequency (percentage) or means (standard deviation), as appropriate. For the effectiveness domain, the mean differences (MD, 95% confidence intervals, effect size [ES]) from baseline to 3-month follow-up were calculated for pain (VAS, 0–100)³⁰; KOOS-12 or HOOS-12 summary measure scores and three subscales of pain, function, and QoL³¹; and physical function (chair stand test).³² Differences were calculated separately for telehealth-only and hybrid model participants. Thresholds for small, moderate, and large ES were ≥0.2–0.49, ≥ 0.50–0.79, and ≥0.80.³³ A responder analysis was conducted by examining the proportion of patients in each group who achieved a minimally clinically important change (MIC) for each primary patient-reported outcome measure—pain (VAS, 15 points)³⁴; KOOS/HOOS-12 summary score (14.9 points), and pain (11.5 points), function (13.7 points), and QoL (5.5 points) subscales³⁵; and chair stand test (two stands).³⁶ Chi-square statistics determined the significance of change in desire for joint replacement surgery from baseline to 3 months in each group. Perceived recovery on a global rating of change and satisfaction with the GLA:D^® program were reported descriptively.

After qualitative and quantitative data were analyzed independently, they were integrated and synthesized into a joint display based on our conceptualization of the RE-AIM QuEST dimensions in Table 1.

Results

Twenty-three physiotherapists (14 [61%] female, 19 [83%] private practice, 20 [87%] urban clinic location) from 5 Australian states (Victoria, Western Australia, Tasmania, South Australia, and New South Wales) engaged in semistructured interviews. Twelve were adopters, and 11 were nonadopters. Median duration of interviews was 27 min (range = 14–48 min). Two physiotherapist participants provided additional comments supporting the themes identified from the analysis via email follow-up. The qualitative themes and subthemes with supportive data quotations from physiotherapists related to GLA:D^® via telehealth are organized by RE-AIM dimensions in Table 2. Additional qualitative data is available in Supplemental Appendix B.

Table 2.

Qualitative themes from physiotherapist GLA:D^® telehealth adopters and nonadopters.

Themes	Adopters (n = 12)	Nonadopters (n = 11)
REACH: Perceived patient barriers (B) and facilitators (F) to GLA:D^® telehealth
1: Technology literacy (B/F), connectivity (B), and equipment access (B) Confidence and familiarity with technology were considered a key barrier or facilitator for patients by adopters. Age was emphasized as a factor influencing technology literacy by nonadopters.	“Patients do need a certain amount of confidence with technology…There are certainly some people who took a few attempts to get telehealth right.” PT 12 adopter “I think for people who aren't used to online technology for communication and things like that, convincing them that it's a good idea can be hard.” PT11 adopter	“With older clientele who are probably less familiar with the technology… they find it a little bit too complicated to know how to get a Zoom or access webcam or use their computers.” PT14 nonadopter “How computer savvy the patients are…some clinics that perhaps have that slightly older 70, 80 [year old] demographic, they might struggle a bit.” PT16 nonadopter
2: Convenience and flexibility (F) Both adopters and nonadopters felt telehealth improved accessibility to GLA:D® for patients by reducing the need to travel and providing an alternative option for people with work or caring responsibilities.	“One of the guys was always travelling … he did do the exercises he carried his equipment in kits.” PT2 adopter “I think telehealth definitely has great options…GLA:D®‘s not everywhere obviously.” PT3 adopter	“People that are hour and a half away that aren’t gonna come in twice a week – if that's gonna be a barrier for them entering the program – so, I certainly think telehealth would break down some of those barriers.” PT19 nonadopter “Maybe people that are working a lot … or maybe people that travel?” PT22 nonadopter
3: Perceived telehealth value highly influenced by exposure to telehealth (B/F) Both groups felt patients preferred in-person GLA:D® and that telehealth was considered lower value due to concerns about effectiveness, lack of hands-on care, and not using gym equipment. Adopters stated many patients were initially hesitant, yet after experiencing GLA:D® via telehealth they better appreciated its value. Some adopters felt they needed to encourage patients to be open to trying GLA:D® via telehealth.	“Whether people felt as though they were getting value – that was generally prior to doing it. Generally, once they’d done the classes, they went, ‘Oh, this is actually really useful. I’m finding it really helpful for motivation and supervision and keeping me accountable.’” PT6 adopter “I think it can be a little bit harder to get by from participants who aren't familiar with telehealth…it takes a bit longer for them to believe that not having hands-on therapy is gonna be effective.” PT11 adopter	“I think there's probably a little bit of resistance from patients as well early on to do an online variation of the program.” PT4 nonadopter “I wonder if they think they feel like they get value when they’re there with you in the flesh.” PT22 nonadopter
4: Home environment: motivation (B/F), space (B), and equipment (B) Both groups felt that patients found doing GLA:D® via telehealth in the home environment was a challenge due to lower motivation, lack of specialized equipment, and not having space or privacy. However, some saw the home environment as an opportunity to improve patient confidence with exercise and to facilitate exercise maintenance.	“Doing [exercise] in your own home is not as appealing.” PT7 adopter “People felt motivated that after doing the program supervised at home, they were then quite quick to transition to an independent home-based program.” PT 12 adopter	“People just sort of popping in or out, or doors opening, and external noise going on, or tradies in the house next-door …that was probably a barrier.” PT4 nonadopter “They kind of got a bit anxious and worried about the fact of how to do it, in the home environment… and the setup from that point of view.” PT 23 nonadopter
5: Pandemic restrictions (B/F) Both groups felt limited in-person care options during pandemic restrictions increased patient uptake of GLA:D^® via telehealth. Conversely, lockdown unpredictability was seen as a barrier, where patients felt they could just wait.	“[Telehealth] was more out of necessity. … that people still wanted ongoing treatment but weren’t eligible to come in for the clinic.” PT12 adopter “Most people said, ‘It's too hard. I haven’t done it before. I’ll just wait,’ because they didn’t feel that the effort was worth it for one or two weeks.” PT8 adopter	“Patients still see the value in [telehealth], but that value would go up if we’re in a scenario where no one could go out and do something else as well.” PT19 nonadopter “I think the problem was more about getting people engaged in that at that time [lockdown] was a stressful time.” PT13 nonadopters
6: Safety concerns (B) Adopters felt that GLA:D^® via telehealth was not appropriate for frail individuals. An assessment was essential for all patients. Only a small subset of patients should be excluded from telehealth.	“It was more the older, more frail people where balance might have been an issue that made me nervous [about telehealth].” PT8 adopter “Making sure that the person is suitable and capable of being safe in an online group, and that comes from doing a comprehensive assessment. “PT1 adopter	NA
EFFECTIVENESS: Perceived effectiveness
1. Adopters felt GLA:D^® via telehealth was as effective as in-person, whereas nonadopters felt GLA:D via telehealth would be less effective overall than GLA:D^® in-person. Adopters said that delivery mode was not the primary determinant of GLA:D^® effectiveness. Adopters felt patients were empowered and better able to continue exercising at home after GLAD^® via telehealth. Nonadopter still perceived GLA:D^® via telehealth as effective, yet many felt it would be generally less effective than in-person.	“I don’t think…whether the delivery mode was online or face to face [mattered] because I have got successful, really good results with telehealth.” PT2 adopter “’[Telehealth] is definitely a very viable option and a very effective way of delivering the program… patients improved. They improved their function. They generally completed the program. Their routine getting into that exercise, their willingness to get out and have a bit of a go, and dispelling their fears around exercise improved, and you could give that constant reassurance.” PT3 adopter	“For the average patient who comes in who's got moderate osteoarthritis and functionally they’re not too bad, I don’t think there's a lot of difference [between in-person or telehealth].” PT4 nonadopter “Whether they would be quite as good as what we’d get in a [in-person] clinical setting I’m a touch sceptical on.” PT19 nonadopter
2. Adopters considered both hybrid and telehealth only-models to be effective.	“A hybrid model would be awesome for people …maybe the first three weeks in person to really nail technique… then almost last three weeks via Telehealth so that they can learn to exercise in their own home environment.” PT1 adopter	NA
ADOPTION: Perceived barriers (B) and facilitators (F) to adoption
1: GLA:D^® via telehealth was generally perceived as a normal part of practice (B/F) For adopters, telehealth became a normal part of practice, they liked it, but still preferred in-person. Nonadopters were aware of telehealth but didn’t feel it was needed.	“I do see telehealth being a part of my role as a physiotherapist…the world is changing and that we have to change to keep up with it.” PT11 adopter “I kind of see telehealth as a normal part of practice now anyway.” PT5 adopter	“I don’t choose to do [telehealth] at the moment, there's no need for it, and I think it's a better option to see people in person… I can imagine that in time…I’ll need to do a bit of both and I’m quite happy to do that.” PT13 nonadopter “I would still prefer in person, but I guess if we had a demand, like we had a few patients ask for it, I’d be happy to do it.” PT16 nonadopter
2: GLA:D^® via telehealth was believed to facilitate continuity of care for adopters (F)	“A lot of clients to be missing out on therapy due to COVID… there was a demand and a need, given how long my GLA:D^® waitlist, is to offer something.” PT1 adopter “[Telehealth is] a really big advantage in terms of continuity of care.” PT11 adopter	NA
3: Adopters gained confidence delivering GLA:D^® via telehealth through experience, whereas nonadopters were less confident.	“My learning curve was very steep as I went from doing not a lot of Telehealth at all to having to do it for every consultation…there was also a lot of unknowns…there was definitely a bit of anxiety …but I’m pretty confident now.” PT7adopter “Once you’d done a couple, it was like – yeah, this is okay, it's going to work. And we learned as we went.” PT3 adopter	“Our capabilities as physios to do online exercise groups, we just – we haven’t been trained or there's a lot of skills that we probably would need to develop … I think it would make me quite stressed.” PT17 nonadopter “We put a lot of pressure on physios to do something that is just not their thing or without maybe the adequate training.” PT17 nonadopter
4. Both groups reported a lack of knowledge, training, and resources for delivering GLA:D^® via telehealth (B/F)	“To have a bit more resources that you could offer patients … like a video that patients could see and understand what a telehealth session is, whereas I think telehealth has been mentioned in the news a lot and certainly general practitioners use it a lot but they tend to just use it as a phone call, which I think is very, very different to the way physios utilize it.” PT 12 adopter	“There weren’t any advice or resources around strategies for [telehealth], then it’d be great and really beneficial for us.” PT14 nonadopter
5. Nonadopters felt GLA:D^® via telehealth adoption was unnecessary due to low patient demand (B)	NA	“We haven’t really had the need to do it via telehealth.” PT 18 nonadopter “I think we debated doing a bit of telehealth…but the way we were running we went, ‘Look, if we can still get people in –’ it's a little bit easier.” PT19 nonadopter
IMPLEMENTATION: Program modifications, implementation supports, and resources
1: GLA:D^® via telehealth implementation involved numerous program modifications & challenges Adopters made adaptations to ensure program integrity and patient safely. This included patient assessments, how and which exercises were prescribed, class size and structure, and patient fees. Nonadopters perceived they would need to make changes to how they taught exercises and anticipated smaller class size.	“You don’t necessarily need to be putting your hands on [to assess]…that might be 30 s worth…most of the other information we get about that kind of diagnosis and planning is with our eyes, and our ears, and our brains, which we still have over a computer.” PT6 adopter “Being confident in your own description of the exercises … Keeping it as simple as possible is really important.” PT3	“If the patient can’t effectively show you or demonstrate and you can’t see what they’re doing, there's just a bit of a margin for error there that you wouldn’t be able to correct the technique if you can’t see it properly. You’ve lost that three-dimensional look.” PT17 nonadopter “I think certainly [telehealth] group sizes perhaps needed to be a little smaller from what we currently run.” PT 14 nonadopter
2: Adopters felt GLA:D^® via telehealth had social benefits for patients, while nonadopters felt the social benefit would be diminished compared to in-person. Adopters said the social dynamic was different and it was more challenging to facilitate compared to GLA:D^® in-person.	“Humans are social creatures and you sort of lose that when everyone's in their individual rooms online. Yes, you can still see them. Yes, you still engage with them, but it's a different engagement.” PT5 adopter “There's still a lot of chatter going back and forth. It actually can be quite fun especially when they’ve gotten to know each other.” PT6 adopter	“Face-to-face you can have a bit more of a casual joke with them and things like that.” PT4 nonadopter “Building rapport, that might be more difficult with telehealth classes from start to finish because then my concern would be to get to know them as well … I don’t know if that would be more difficult, more challenging in a telehealth versus an in-person context.” PT 21 nonadopter
3: Adopters used a variety of Implementation supports and resources Adopters spoke positively about and used a wide variety of resources to assist with implementation and also developed their own materials.	“There were some other telehealth resources, webinars that…were really helpful… it all sort of fell into place because we had some guidelines and structure.” PT3 adopter “Using the TREK website that has all of the exercises on it and progressions, really nice quality videos there, being able to .. share your screen with the patients …I found to be quite effective.” PT11 adopter	NA
MAINTAINENCE: Perceived role of telehealth in future; barriers (B) and facilitators (F) to sustainability
1: GLA:D^® via telehealth should continue in a small capacity in the future Adopters were positive about providing ongoing GLA:D^® via telehealth in the future. Some nonadopters thought GLA:D^® via telehealth should continue, but were concerned about low patient preference and lack of demand.	“I think the demand for Telehealth has been a little bit less but, as I said, I’ve still got probably a handful of people that are very keen to continue doing it.” PT7 adopter “I think that telehealth will be a part of [GLA:D^®] in the future and hopefully, more and more people become accustomed to it.” PT12 adopter	“My impression is probably not because I just don’t think the demand would be there.” PT 4 nonadopter “I think patient demands will drive our practice and they should.” PT17 nonadopter
2. Effective communication strategies are important for sustainability of GLA:D^® via telehealth (F) Adopters felt promotion to the public and better communication with patients was needed to enable sustainability of telehealth.	“The Australian Physio Association created lots of resources around [telehealth] as well.. I think governing bodies that promote stuff in the public realm to say [telehealth] is trustworthy, and possible, and available is helpful.” PT5 adopter “I made a big effort and actually communicate with every one of my patients…to explain the process … and really smooth out any concerns about the Telehealth process. … being able to field all those questions early and having that communication with each individual was really helpful.” PT7 adopter	NA
3: Personnel capacity and workplace logistics (B) Both groups felt a lack of trained PTs and resources could limit the future sustainability of GLA:D^® via telehealth.	“It's just availability of practitioners.. and availability of practitioner hours.” PT20 adopters “If we had additional staff, yeah, we may very well have continued to offer [telehealth], particularly for people that struggled to get to our set times which are daytimes, so those working.” PT11 adopter	“I’m not convinced we have probably the time or the resources to do with the combination of both [in-person and telehealth] at the same time.” PT18 nonadopter “From the physio service, and we’re a busy clinic anyway so we don’t have – we can’t do everything anyway, it's not like we need more that we can’t fit in.” PT13 nonadopter
4: GLA:D^® via telehealth as an opportunity to improve access to high quality care for people from rural areas or with work/caring demands (F).	“[Telehealth facilitates] getting good quality services to people who might struggle to access it otherwise.” PT6 adopter “I think [telehealth] will probably become a bigger part of us … occasionally we’ll get patients from country areas that will come down…I feel like those people will really, really benefit greatly from telehealth going forward.” PT8 adopter	“I think Australia's one of the perfect environments for telehealth…you could transfer that over to really remote communities.” PT17 nonadopter “With people that don’t necessarily have close access or have to travel a distance to get to a GLA:D^®… if that was actually more rural would be very helpful.” PT23 nonadopter
5: Training and resources are needed to ensure future high quality GLA:D^® via telehealth (F) for both groups.	“Maybe some short videos, even some example case study… actually watching an appointment… Maybe some specific assessment points around the specific joints or parts of the body would have been helpful.” PT 7 adopter “I’m a big fan of ongoing training…I’d definitely be happy with some more training…get together a big group of experienced clinicians and talk about telehealth and have a forum or education session on it.” PT15 adopter	“Whether that's in the form of an informal one, two-hour setting or whether that's through an actual full-on interactive one-day course.” PT 21 nonadopter “Certainly some resources and professional development on implementing telehealth-specific group-based therapy would be I think really beneficial.” PT 14 nonadopter

B: barrier; F: facilitator; PT: physiotherapist; TREK: translating research evidence and knowledge.

During the 2-year study period, 5465 participants registered in the GLA:D^® Australia patient data registry. Of these, 3712 (68%) participants completed baseline questionnaires and 2612 (48%) participants completed 3-month follow-up questionnaires. Of the 2612 participants, the reach of GLA:D^® by telehealth-only delivery and hybrid delivery was 85 (3%) and 115 (4%), respectively. From 2141 GLA:D^®-trained physiotherapists in Australia, 128 (6%) adopted the delivery of GLA:D^® by telehealth-only delivery or hybrid model for at least one patient.

Figure 1 illustrates the timing of when patients completed 3-month data registry questionnaires across the study period by telehealth-only or hybrid groups. Quantitative effectiveness outcomes from the GLA:D^® patient registry at baseline and 3-months for telehealth-only and hybrid GLA:D^® delivery are provided in Table 3. GLA:D^® by telehealth-only had larger ESs on all outcomes compared with hybrid delivery. Group-level mean changes exceeded MIC values for KOOS/HOOS-QOL and chair stand test for both delivery models, but not for pain (VAS) or KOOS/HOOS-pain, function, or summary score. At an individual level, 62% (n = 122) patients reached MIC for KOOS-QOL and 74% (n = 58) for chair stand test. Overall, 82% (n = 70) and 78% (n = 90) of patients achieved a MIC for at least one primary outcome at 3-month follow up in telehealth-only and hybrid groups, respectively (Table 3). In telehealth-only and hybrid models, 88% (n = 73) and 73% (n = 84)) reported recovery (slightly, strongly, or completely recovered), and 99% (n = 82) and 85% (n = 97) were satisfied or very satisfied (Figure 2). At baseline, 28% (n = 24) and 30% (n = 35) of participants desired joint replacement surgery, which decreased to 21% (n = 18) and 23% (n = 26) at 3-month follow-up in telehealth-only and hybrid groups, respectively (chi-square, p < .001; both groups).

Figure 1.

Hybrid and telehealth-only GLA:D^® patients completing 3-month registry outcomes.

Figure 2.

Global rating of change scores (2a) and GLA:D program satisfaction (2b) self-reported by patients with knee and hip osteoarthritis. *: missing n = 2.

Table 3.

Quantitative effectiveness outcomes from GLA:D^® patient registry for hybrid and telehealth-only GLA:D^® delivery.

Outcome	Delivery model	Baseline, mean (SD)	3-month, mean (SD)	Mean difference (95%CI)	Effect size	Responders% (n)
Pain* (VAS, 100 m)	Hybrid (n = 114)	45 (21)	39 (25)	6 (2, 10)	0.25	33% (37)
Pain* (VAS, 100 m)	Telehealth-only (n = 82)	47 (22)	34 (22)	13 (8, 18)	0.60^α	45% (37)
KOOS-12/ HOOS-12	Hybrid (n = 114)	51 (15)	58 (19)	7 (4, 10)	0.50^α	23% (26)
KOOS-12/ HOOS-12	Telehealth-only (n = 83)	51 (16)	62 (17)	11 (8, 13)	0.81^α	39% (32)
KOOS/ HOOS-QOL	Hybrid (n = 114)	41 (18)	50 (20)	9 (6, 12)	0.52^α	62% (71)
KOOS/ HOOS-QOL	Telehealth-only (n = 83)	43 (18)	54 (17)	11 (8, 15)	0.71^α	61% (51)
KOOS/ HOOS-FUN	Hybrid (n = 114)	61 (18)	66 (21)	6 (3, 9)	0.36	26% (30)
KOOS/ HOOS-FUN	Telehealth-only (n = 83)	60 (19)	69 (19)	9 (6, 13)	0.57^α	34% (28)
KOOS/ HOOS-PAIN	Hybrid (n = 114)	52 (16)	58 (19)	6 (3, 10)	0.35	38% (43)
KOOS/ HOOS-PAIN	Telehealth-only (n = 83)	51 (16)	62 (18)	11 (8, 15)	0.73^α	52% (43)
Chair stand test	Hybrid (n = 42)	11 (3)	15(5)	4 (3, 5)	1.1^α	74% (31)
Chair stand test	Telehealth-only (n = 36)	10 (3)	13 (3)	3 (3, 4)	1.5^α	75% (27)

α: effect sizes medium or large; CI: confidence interval; FUN: function; HOOS-12 short form: Hip Osteoarthritis and Outcome Score - Short Form; KOOS-12: Knee Injury and Osteoarthritis Outcomes Score - Short Form; QOL: quality of life; VAS: visual analogue scale.

*Mean pain during last month.

A summary of qualitative findings from Table 2 and quantitative effectiveness outcomes from Table 3, along with quantitative results related to reach, adoption, implementation, and maintenance, are provided in a RE-AIM QuEST joint display (Table 4).

Table 4.

Joint display summarizing results of RE-AIM QUEST evaluation of GLA:D® via telehealth.

Dimension	Qualitative themes	Quantitative data
REACH	Perceived patient barriers (B) and facilitators (F) to GLA:D® telehealth reach Technology: Literacy (B/F), connectivity (B), equipment access (B) Convenience and flexibility (F) Perceived telehealth value highly influenced by exposure to telehealth (B/F) Home environment: motivation (B/F), space (B), and equipment (B) Pandemic restrictions (B/F) safety concerns (B)	Participants: n = 200; 139 (70%) female Delivery mode: 115 (58%) hybrid; 85 (43%) telehealth only Joint most affected: 166 (83%) knee; 34 (17%) hip Age: mean 65 years (SD = 9.3) BMI: mean 30 (SD = 5.7) Education: 93 (47%) university degree, 68 (34%) completed apprenticeship, certificate, or diploma, 37 (19%) completed high school, 2 (1%) completed primary school Employment: 89 (45%) employed full or part time, 98 (49%) retired, 7 (3%) home duties, 5 (2%) unemployed, 1 (1%) studying One or more comorbidities: 144 (72%) Location: 119 (60%) metropolitan, 73 (37%) rural, 6 (3%) mixed, [missing 2] Previous surgery on affected joint: 56 (28%)
EFFECTIVENESS	Perceived effectiveness Adopters felt GLA:D® via telehealth was as effective as in-person, whereas nonadopters felt GLA:D® via telehealth would be less effective overall than in-person. Adopters considered both hybrid and telehealth only-models to be effective.	Mean change in pain, quality of life, function, and KOOS/HOOS-12 summary scores indicated improvements between baseline and 3 months for both hybrid and telehealth-only delivery models. The telehealth-only delivery was associated with moderate-to-large effect sizes for all outcomes, whereas small-to-moderate effect sizes were associated with the hybrid delivery model. Improvements in physical function (30 s chair rise) met MIC in both groups. Both groups had a reduced desire for surgery.
ADOPTION	Perceived barriers (B) and facilitators (F) to adoption GLA:D® via telehealth was generally perceived as a normal part of practice (B/F) GLA:D® via telehealth was believed to facilitate continuity of care for adopters (F) Adopters gained confidence delivering GLA:D® via telehealth through experience, whereas nonadopters were less confident. Both groups reported a lack of knowledge, training, and resources for delivering GLA:D® via telehealth (B/F) Nonadopters felt GLA:D® via telehealth adoption was unnecessary due to low patient demand (B)	Physiotherapists: n = 128/2141, 6% Clinics: n = 97 Health service: 79 (81%) private, 17 (18%) public, 1 (1%) mixed State: 49 (51%) Victoria, 12 (12%) Queensland, 12 (12%) South Australia, 10 (10%) NSW, 8 (8%) ACT, 3 (3%) Western Australia, 2 (2%) Tasmania, 1 missing Location: 63 (65%) metropolitan, 30 (31%) rural, 3 (3%) mixed (1 missing)
IMPLEMENTATION	Program modifications, implementation supports, and resources GLA:D® via telehealth implementation involved numerous program modifications and challenges Adopters felt GLA:D® via telehealth had social benefits for patients, while nonadopters felt the social benefit would be diminished compared to in-person. Adopters used a variety of implementation supports and resources	173 (87%) attended 10 or more exercise therapy sessions 141 (71%) attended two education session Hybrid group completed a median of 6 (IQR = 4, 9) telehealth exercise sessions Of the 115 completing hybrid, 61 (59%) intended in-person, 33 (32%) intended telehealth, 7 (6%) intended hybrid, and 3 (3%) intended a home program prior to starting (missing 11). Of the 85 completing telehealth-only, 38 (45%) intended in-person, 43 (51%) intended telehealth, and 3 (4%) intended hybrid (missing 1).
MAINTAINENCE	Perceived role of telehealth in future; barriers (B) and facilitators (F) to sustainability GLA:D® via telehealth should continue in a small capacity in the future Effective communication strategies are important for sustainability of GLA:D® via telehealth (F) Personnel capacity and workplace logistics (B) GLA:D® via telehealth as an opportunity to improve access for people from rural areas or with work/caring demands (F) Training and resources are needed to ensure future high quality GLA:D® via telehealth (F)	GLA:D® hybrid and telehealth-only delivery patients completed 3-month data registry questionnaires across the full study period. The number of patients receiving hybrid delivery peaked in June 2020, suggesting many may have had a forced transitioned from in-person delivery at the start of the pandemic. Conversely, the number of patients receiving telehealth-only delivery peaked later (Nov 2020) when telehealth delivery was more established. (Figure 1)

ACT: Australian Capital Territory; B: barrier; BMI: body mass index; F: facilitator; HOOS-12: Hip Disability and Osteoarthritis Outcome Score-Short Form; IQR: interquartile range; KOOS-12: Knee Injury and Osteoarthritis Outcome Score-Short Form; MIC: minimally clinically important change; NSW: New South Wales; SD: standard deviation.

Discussion

Our comprehensive mixed-methods evaluation indicates high rates of patient satisfaction and self-reported recovery following access to GLA:D^® via telehealth-only and hybrid models in Australia during the COVID-19 pandemic. While the overall reach to patients with knee and hip OA was low, demographics (age, BMI, education, comorbidities) of those accessing telehealth delivery models are comparable to people accessing in-person delivery of GLA:D^®.¹¹ Adoption among trained physiotherapists was widespread geographically, occurring in seven of eight states and territories. However, overall adoption was limited, with only 6% (128/2141)³⁷ of trained physiotherapists providing GLA:D^® via telehealth during our two-year evaluation period. Our qualitative findings found that low adoption likely reflects a variety of factors including physiotherapists lack of confidence and training in telehealth, their preference for in-person care, beliefs about patient preferences, as well as therapist and clinic-level capacity limitations to deliver telehealth. Our in-depth interviews with physiotherapist adopters and nonadopters identified key barriers and facilitators at patient, clinician, and systems levels, which will inform implementation strategies to maintain or potentially scale up group education and exercise therapy programs like GLA:D^® via telehealth in Australia and internationally in the future.

This evaluation is one of the first to examine the effectiveness of telehealth care in a real-world setting and uniquely focuses on group-based exercise therapy.³⁸ Our quantitative findings, especially in the telehealth-only cohort, are highly comparable to previously published data on in-person GLA:D^® provided in Australia¹¹ and internationally.^12–14 This includes similar clinically important improvements in KOOS/HOOS-QOL scores (MD = 9–11) and physical function measured by the chair rise test (MD = 3–4),^11,37 and reflects perceptions of effectiveness among adopter and nonadopter physiotherapists in this study. Notably, more than three in four patients accessing GLA:D^® via telehealth achieved a MIC in at least one primary effectiveness outcome including pain, joint-related QoL, and function. Additionally, one in four patients who desired surgery at baseline no longer desired surgery at 3-month follow-up across both groups. Importantly, real-world findings from this study provide further evidence beyond clinical trials¹⁷ that telehealth is associated with similar outcomes to in-person when providing care to people with OA,¹⁷ including our recent noninferiority randomized controlled trial comparing GLA:D^® via telehealth.¹⁹

Telehealth-only delivery of GLA:D^® appeared to produce superior outcomes compared with hybrid delivery. A possible explanation for this may be the circumstances surrounding the timing of delivery. Hybrid delivery of GLA:D^® peaked very early in the pandemic (Figure 1), when it is likely that many patients who had begun in-person GLA:D^® were forced to transition to telehealth delivery due to government-imposed restrictions on in-person care. Notably, only 7% of those who received GLA:D^® via hybrid delivery, intended to receive hybrid delivery at baseline. Conversely, in the telehealth-only group, where registration was highest following initial lockdown periods, 51% of these patients intended to complete GLA:D^® via telehealth-only at baseline. Thus, these individuals may have been more prepared for, and accepting of, a telehealth delivery model.⁴⁰ Our qualitative findings support this, where physiotherapist adopters discussed the importance of adequately preparing patients for telehealth, including answering questions, providing reassurance, setting expectations, and providing technology troubleshooting. Early in the pandemic, with the abrupt transition to telehealth,⁴¹ it is unlikely that hybrid delivery patients received adequate support.

Physiotherapist adopters in this study perceived GLA:D^® via telehealth to be acceptable as part of normal practice. They enjoyed providing telehealth and believed it facilitated the continuity of care for some patients. Conversely, nonadopters were aware that GLA:D^® could be delivered via telehealth, but they did not perceive it to have advantages that would make it viable to implement. This finding is consistent to previous work exploring patient acceptability of GLA:D^® via telehealth, which indicates that acceptability of telehealth delivery is highly influenced by exposure.¹⁸ This highlights that for both physiotherapists and patients, the value of telehealth is often not realized until it is experienced. There may be a role for greater awareness and education to the public as well as communications and training for physiotherapists on the potential advantages and opportunities for telehealth.

Telehealth delivery of GLA:D^® was implemented with high patient adherence to exercise therapy and education, with 87% attending 10 or more exercise-therapy sessions and 71% attending both education sessions across groups. This adherence to telehealth GLA:D^® is higher than the attendance reported to in-person GLA:D^® in Australia, where a program evaluation reported 78% attended 10 or more exercise-therapy sessions and 58% attended both education sessions. Greater adherence in this study may reflect a key advantage of telehealth to patients, the convenience and flexibility it offers. Physiotherapists in this study highlighted this benefit of telehealth, and it also echoes previous interviews with patients who had received care via telehealth.^18,40

Physiotherapist adopters discussed making many modifications to facilitate implementation, including conducting patient assessments, how exercises were taught, smaller class size, different class structure, and reduced program costs to patients. Similarly, a retrospective evaluation of telehealth-delivered physical therapy implemented in an academic medical center summarized numerous implementation strategies, including promoting adaptability and changing physical structure and equipment for programs.³⁸ Charging lower fees when providing physiotherapy via telehealth has previously been discussed^41,42 and may reflect limited funding support for telehealth and the perceived inferior value of telehealth by patients.

Physiotherapist adopters spoke positively about the potential advantages of GLA:D^® delivered in a hybrid model as it facilitates exercises to be initially taught in-person, but later transitioning patients to be able to perform supervised exercise in their home environment. Previous qualitative interviews with Australian patients⁴⁰ and surveys of Canadian physiotherapists⁴² suggest a hybrid delivery model may be a viable and acceptable option for patient care in the future. Considering apparent inferior outcomes with hybrid delivery of GLA:D^® compared to telehealth-only identified in this study, further research is needed to examine the effectiveness of hybrid delivery of GLA:D^® and other musculoskeletal pain care beyond the early stressful phases of the COVID-19 pandemic.

Telehealth GLA:D^® reach to OA patients and adoption by physiotherapists was especially low in publicly funded health services. Low adoption in public health settings has also been reported for in-person delivery of GLA:D^®¹¹ and may reflect challenges in public health settings including obtaining ethics to facilitate data collection, alongside managing more complex or non-English speaking patients compared to private settings.^11,41 Conversely, our qualitative findings from adopter physiotherapists suggested that only a very small number of patients should be excluded from GLA:D^® via telehealth, which would be due to safety concerns. Other patient-level barriers reported by physiotherapists in this study are modifiable, including technology literacy and access, perceived value, and home environment. Our findings suggest the need for implementation strategies to better support patients, including technology training to build confidence and familiarity with computers, clear communication and education about what telehealth involves and its effectiveness to improve perceived value, and instruction on how to modify exercises in the home environment.⁴²

Delivery of GLA:D^® via telehealth was considered to have become a normal part of practice among adopters, with this group valuing telehealth's ability to facilitate continuity of care both during and beyond the pandemic. Consistent with previous survey research,³⁹ both adopters and nonadopters reported limited previous training in telehealth, and a lack of knowledge and confidence in managing patients in this manner. This lack of knowledge and confidence in delivering telehealth may have been a key factor influencing the overall low adoption of GLA:D^® via telehealth. Similar to other qualitative research,⁴³ adopters in this study gained confidence through experience and had a “steep learning curve” where they embraced an attitude of “diving in the deep end.” Comparatively, many nonadopters felt it was “a lot of pressure on physios” to adopt telehealth, and they would be “quite stressed” and therefore did not feel confident to attempt delivery of GLA:D^® via telehealth. Nonetheless, physiotherapists from both groups suggested delivery of GLA:D^® via telehealth should continue beyond the pandemic, to provide care for people unable to access in-person care (e.g., live in rural or remote region), or who can benefit from the convenience and flexibility of telehealth (e.g., carer or occupational responsibilities, immunocompromised). Adopters suggested a multipronged communication strategy was key to increasing community awareness of the advantages of telehealth—with messaging targeting the general public and physiotherapists considered important. Consistent with other reports,^38,42,43 both groups suggested there was a need for future supports, training, and resources for physiotherapists to facilitate greater adoption of telehealth, along with maintenance and scale up of telehealth services.

Several limitations should be considered when interpreting this study's findings. A relatively low number of OA patients were registered in our database as completing GLA:D^® via telehealth. It is possible that many additional patients completed telehealth during this challenging time, yet were not registered by their treating physiotherapist. The constantly changing restrictions to in-person patient care in Australia over the 2-year evaluation period make it challenging to directly compare our findings to any concurrent in-person GLA:D^® delivery. Therefore, we choose to compare our cohort with previously published in-person GLA:D^® data in Australia and internationally. We did not incorporate qualitative data on patient perspectives in this evaluation, as we recently published a qualitative study showing high patient acceptability of GLA:D^® via telehealth.¹⁸ Instead we choose a novel approach for the current evaluation of combining patient reported quantitative data and physiotherapists qualitative perspectives. The COVID-19 pandemic was a very stressful time for physiotherapists and their perspectives on telehealth may change moving forward. Our findings from the RE-AIM QuEST represent GLA:D^® via telehealth delivered in Australia and other countries may have different telehealth experiences. Nonetheless, our results can help to inform the development and implementation of group-based telehealth programs worldwide for OA and other chronic diseases.

In conclusion, our comprehensive mixed-methods evaluation of GLA:D^® delivered via telehealth-only and hybrid models had positive convergent findings supporting an association with high patient satisfaction and effective self-reported and objective health outcomes for people with hip and knee OA. However, reach was limited, possibly due to the limited adoption by trained physiotherapists, and key patient-level barriers including technology literacy and access, and low perceived value of telehealth. Further support is needed to facilitate sustainability and any scale up of telehealth delivery for GLA:D^®, including training and resources for physiotherapists and improved communication about the opportunities for telehealth with the public and patients.

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X231167620 - Supplemental material for Implementation of the Good Life with osteoArthritis in Denmark (GLA:D^®) program via telehealth in Australia: A mixed-methods program evaluation

Supplemental material, sj-docx-1-jtt-10.1177_1357633X231167620 for Implementation of the Good Life with osteoArthritis in Denmark (GLA:D^®) program via telehealth in Australia: A mixed-methods program evaluation by Allison M Ezzat, Joanne L Kemp, Joshua J Heerey, Marcella F Pazzinatto, Danilo De Oliveira Silva, Karen Dundules, Matthew Francis, and Christian J Barton in Journal of Telemedicine and Telecare

Footnotes

Acknowledgements

Thank you to the GLA:D^® Australia-trained physiotherapists who participated in our qualitative interviews and provided input on our data analysis. As well, thank you to the patients with osteoarthritis who provided their data to the GLA:D^® Australia Data Registry, which allowed the evaluation of the program.

Author contributions

Conceptualization and design: all

Collection and assembly of data: AE, JLK, MP, CJB, JH

Interpretation of data: all

First draft of manuscript: AE

Critical revision of manuscript and approval of final version: all

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CJB and JLK are program leads for GLA:D^® Australia, a nonprofit implementation project. Their institution has received payment for training GLA:D practitioners. All authors affirm that they have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript, except as disclosed in an attachment and cited in the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: AE is supported by a Canadian Institute for Health Research (CIHR) fellowship. CJB is supported by an MRFF TRIP Early Career Fellowship (APP1150439), and JKL is supported by an NHMRC Early Career Fellowship (APP1119971). This project received in-kind support from GLA:D^® Australia, a nonprofit implementation project. Funders had no involvement in the study other than to provide funding.

ORCID iDs

Allison M Ezzat

Danilo De Oliveira Silva

Supplemental material

Supplementary material for this article is available online.

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Supplementary Material

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Implementation of the Good Life with osteoArthritis in Denmark (GLA:D ® ) program via telehealth in Australia: A mixed-methods program evaluation

Abstract

Introduction

Methods

Results

Discussion

Keywords

Introduction

Methods

The GLA:D program

Intervention implementation process and support

Data sources and collection

Part 1: Qualitative data

Part 2: Quantitative data

Patient-level data—GLA:D® Australia Registry

Health services-level data

Data analysis

Part 1: Qualitative

Part 2: Quantitative

Results

Discussion

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X231167620 - Supplemental material for Implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia: A mixed-methods program evaluation

Footnotes

Acknowledgements

Author contributions

Declaration of conflicting interests

Funding

ORCID iDs

Supplemental material

References

Supplementary Material

Patient-level data—GLA:D^® Australia Registry

sj-docx-1-jtt-10.1177_1357633X231167620 - Supplemental material for Implementation of the Good Life with osteoArthritis in Denmark (GLA:D^®) program via telehealth in Australia: A mixed-methods program evaluation